November 3, 2007
Diagnosis and Symptoms, Type 2
Question from Sandy, Utah, USA:
I am a 43 year old Caucasian female, diagnosed with type 2 diabetes about a month ago. My blood glucose was 128 mg/dl [7.1 mmol/L] five hours after the last time I ate, so my doctor later ordered an A1c, which was 5.3 (with a glucose of 148 mg/dl [8.2 mmol/L] at that time). I’m now taking metformin and am scheduled for another A1c in a couple of months. I’m confused about my diagnosis because I am thin (BMI = 19.5), very active, have a good (low fat) diet, am asymptomatic, and have no family history of diabetes. My blood pressure, cholesterol, and triglycerides are normal. I wondered about LADA (have been hypothyroid for many years), but both GAD and ICA antibodies were negative, which my family practice doctor says means I have type 2. Could I still have type 1? Does it matter? Is it worth re-testing for autoantibodies and, if so, at what time interval? I’m trying to decide if I should just wait awhile and see how my response to metformin is, or try to see an endocrinologist.
I had a series of appointments with my family practitioner over the summer because of several symptoms, which have recently remitted, after troubling me for several months. The major issues were severe swelling and pain of several knuckles on my right hand, burning chest pain with decreased peak flow and consequent exercise intolerance. I was referred to a rheumatologist at the University of Utah who did a bunch of tests (many negative autoantibody tests, including ANA and double-stranded DNA. Normal pulmonary function testing except about 30% lower than expected peak flow and non-responsive to albuterol. Normal hand x-ray) and declared that he didn’t believe I currently had an autoimmune disease.”Come back if another joint blows up,” he said. In reviewing the rheumatologist’s report, my doctor noticed that a random laboratory glucose had been 128 mg/dl [7.1 mmol/L], so he repeated it with similar results (about 120 mg/dl [6.7 mmol/L]; I hadn’t eaten for at least four hours), so I got the A1c (5.3) a few days later and was diagnosed based on that. None of my fasting values have been over 100 mg/dl [5.6 mmol/L].
My understanding is that it can take years for symptoms of lupus (or rheumatoid) to add up to enough factors to get diagnosed, but if it were an autoimmune syndrome causing my glycosemia (and/or hypothyroidism, and possibly joint pain), it seems like SOME autoantibody would be positive by now.
Maybe I should add that I have severe stress (I know, probably everybody says that). I am divorced, have five kids (ages eight to 16) — four with an undiagnosed, progressive neuropathy (peripheral, axonal, nondemyelinating) and one of those has very limited physical and cognitive function. Another one is bipolar and the “healthy” one was hospitalized a year ago after attempted suicide. I’m also recovering from a five year history of eating disorders and wondering if that had some destructive effect on my metabolism.
I do not see that you have met the criteria for diabetes. The criterion for diabetes is a fasting glucose of greater than or equal to 126 mg/dl [7.0 mmol/L] on more than one occasion (not a random glucose). The A1c studies have all been normal. The antibody tests are superfluous if you do not have diabetes. If you were to have diabetes, the antibodies are helpful, if they are positive. They do not rule out type 1 diabetes if they are negative. I would strongly challenge the diagnosis. You do not want to have diabetes on your medical record if you really do not have it. It is all an insurance company needs to discriminate against you and charge unbelievable premiums.